Form F 1 Le – Fill Out and Use This PDF

The F-1(LE) Medical History Statement serves as a comprehensive document required by the Criminal Justice Education and Training Standards Commission and the Criminal Justice Standards Division for prospective criminal justice officers in North Carolina. It is designed to gather in-depth medical history information prior to a physical examination, aiming to ensure that applicants meet the health requirements necessary for certifiable positions within the field. Those interested in pursuing a career in criminal justice are encouraged to accurately complete the form and present it during their medical examination.

To get started on fulfilling your career aspirations in criminal justice, click the button below to fill out the F-1(LE) form.

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Form F 1 Le PDF Details

Seeking employment within the realms of criminal justice and law enforcement demands a thorough evaluation of an applicant's physical and mental health. The Medical History Statement Form F-1(LE), revised in June 2011, serves this very purpose, under the auspices of the Criminal Justice Education and Training Standards Commission's Criminal Justice Standards Division. Located within North Carolina, yet with implications that resonate broadly, this mandatory document requires completion by applicants aiming for certifiable positions, before undergoing a physical examination. It is a comprehensive form, encompassing a wide array of questions that delve into an applicant’s medical history, current medications—including over-the-counter drugs and prescriptions, allergies, past hospitalizations, surgeries, and detailed inquiries into any history of diseases or conditions across various bodily systems. Notably, it also encompasses questions tailored to identify any potential limitations that could affect an applicant’s ability to perform the duties associated with law enforcement roles. This form, while stringent in its requirements for honesty and completeness, underscores a crucial balance between the need for operational readiness within the force and the overarching responsibility towards the health and safety of its personnel. Moreover, the commitment to confidentiality and the serious implications for falsifying information reflect the high standards upheld within the criminal justice field. Through this scrutiny, the F-1(LE) form plays a pivotal role in ensuring that those serving in law enforcement are physically and mentally prepared for the demands of their critical positions.

Question	Answer
Form Name	Form F 1 Le
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	Crohns, nc form f 1, nc bar assoc form no 1 f, F-1

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CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION

CRIMINAL JUSTICE STANDARDS DIVISION

Post Office Drawer 149, Raleigh, NC 27602

Telephone: (919) 661-5980

Fax (919) 779-8210

MEDICAL HISTORY STATEMENT	Form F-1(LE)
	(Rev. 6/11)

This information is for official use only and will not be released to unauthorized persons. Payment for services rendered is the responsibility of the hiring agency or the individual.

The Criminal Justice Standards Division is NOT responsible for payment.

Mail form to hiring agency or individual

DO NOT mail form to Criminal Justice Standard Division

Instructions:

To be completed by applicant for a certifiable position prior to the physical examination and presented to the examining qualified medical professional (Physician, Physician’s Assistant, or Nurse Practitioner licensed to practice medicine in North Carolina), or Physician and/or Surgeon authorized to practice medicine in accordance with the rules and regulations of the U.S. Armed Forces, at the time of examination [12 NCAC 9B .0104(a)]. All questions must be answered completely and accurately. The original or a copy must be retained in personnel files by the appointing agency.

Date: _____________________

Name: _________________________________________________________ Date of Birth: _____________________

LastFirstMiddle

Address: ____________________________________________________________________________________________

City: ___________________________________ State: ___________________ Zip Code: _____________________

Telephone: ___________________________________ Last 4 Digits of SSN: ______________________________

Current Medications

Prescription Medications: (Include pain relievers, birth control pills, etc.)

______________________________________________________________________________________________________________

Over the Counter Medications: ( Include all cold allergy, headache, vitamins, supplements, herbal remedies, etc.)

______________________________________________________________________________________________________________

Allergies

Drug Allergies: (Include your reaction to the mediation)

______________________________________________________________________________________________________________

All Other Allergies: food, insects, seasons, animals, materials, etc. (Include reaction)

______________________________________________________________________________________________________________

Page 1 F-1(LE) Rev. 6/11

Past Medical History

List ALL hospitalizations and operations since childhood:

(Include type of surgery, date of surgery, any complications or other significant information)

___________________________________________________________________________________________________________

Have you EVER, in your life, had any of the following types of medical problems? [check all that apply to you]

1. CANCER: any type of cancer including skin cancer, breast cancer, and leukemia?

2. MAJOR INFECTIOUS DISEASE: such as tuberculosis, hepatitis, HIV/AIDS, rheumatic fever and others?

3. NEUROLOGICAL PROBLEMS: such as seizure disorder, stroke, concussion, severe headache, skull fracture, recurrent vertigo, balance problems, encephalitis, meningitis, tremors, multiple sclerosis, Huntington=s chorea, peripheral neuropathy and others?

4. PSYCHOLOGICAL PROBLEMS: such as depression, manic episodes, psychotic episodes, post traumatic stress disorder and others?

5. EYE PROBLEMS: such as eye injury, color blindness, poor night vision (night blindness), glaucoma, blindness in one or both eyes, very poor vision when not corrected and others?

6. EAR PROBLEMS: such as ear injury, chronic ringing (tinnitus), chronic or long lasting ear infection, Meniere=s disease, moderate to severe hearing loss in one or both ears and others?

7. NOSE PROBLEMS: such as nose injury, allergies, nasal bleeding, loss of sense of smell, chronic or long lasting infections and others?

8. MOUTH OR THROAT PROBLEMS: such as injury, major dental work, any kind of speech defect, chronic or long lasting infections, abnormality of nose, mouth or throat that would interfere with wearing a respirator and others?

9. LUNG PROBLEMS: such as asthma, emphysema, chronic or recurrent bronchitis, pneumonia, tuberculosis or lung abscess and others?

10. HEART AND CIRCULATION PROBLEMS: such as heart murmur, heart disease, heart attack, hypertension (high blood pressure) irregular rhythm, valve abnormalities, varicose veins, phlebitis, peripheral vascular disease, Raynaud=s disease and others?

11. DIGESTIVE SYSTEM PROBLEMS: such as any kind of ulcer disease, hepatitis or liver disorder, any kind of colitis, Crohn=s disease, ulcerative colitis, irritable bowel syndrome, esophageal disorders, pancreatitis, gall stones, stomach or intestinal bleeding and others?

12. HORMONE OR ENDOCRINE PROBLEMS: such as diabetes, thyroid disease, parathyroid or adrenal problems and others?

13. URINARY TRACT PROBLEMS: such as kidney stones, pyelonephritis (kidney infection), nephrosis, single functioning kidney, polycystic kidney disease, repeated bladder infections and others?

14. HERNIA: such as inguinal, umbilical, ventral, femoral, hiatal or incisional hernias?

15. MUSCLE, BONE AND JOINT PROBLEMS: such as chronic back or neck pain, numbness fibromyalgia, back or neck disk disease, osteomyelitis (bone infection), muscular dystrophy, arthritis, spinal curvature, carpal tunnel syndrome loss of a finger or toe, and others?

16. BLOOD SYSTEM PROBLEMS: such as anemia, hemophilia or bleeding disorder, white blood cell abnormality and others?

(Continued on next page)

Page 2 F-1(LE) Rev. 6/11

Males Only:

17. Prostate problems such as enlargement or prostatitis?

18. Genital problems such as epididymitis or testicular injury?

Females Only:

19. Currently pregnant?

20. History of endometriosis, pelvic inflammatory disease, abnormal Pap smear, PMS or other problem with your menstrual cycle?

Immunizations

21. Have you ever had a positive TB test?

22. Have you received Hepatitis B vaccinations?

23. When did you receive your last tetanus (lockjaw) immunization? __________________________________

Occupational History

Have you ever been exposed to any of the following, whether at home, work, military or any other setting? [check all that apply]

24. Repetitive Loud Noises (Including guns, jet engines, loud machinery)?

25. Chemical exposure to skin or lungs?

26. Dusty conditions (sandblasting, grinding, mining or drilling of rock, coal, silica, asbestos)?

Check all YES answers:

27. Have you ever sustained an injury while at work that necessitated extended care by a health care provider?

28. Have you ever had a motor vehicle accident or other injury event causing back or neck pain?

29. Are you limited or unable to perform any physical activity because of muscle or joint discomfort?

30. Do you have any missing limbs or non-functional joints?

31. Do you have numbness, weakness, or pain in your upper extremities (including your hands)?

32. Have you ever been advised by a physician to avoid sitting or standing over a certain time?

33. Have you ever worked in law enforcement?

33a.If yes, have you ever missed more than three consecutive days of work for any medical or psychological problem?

34. Have you ever served in any of the armed forces?

34a.If yes, have you ever missed more than three consecutive days or service for any medical or psychological problem?

35. Do you have any medical condition that would prevent you from working extended shift periods, rotating shifts, or night shifts?

36. Do you have difficulty sitting for any extended period of time?

37. Have you ever been advised by a physician to avoid lifting above a certain weight limit?

38. Do you have any difficulty in properly holding, aiming or firing a handgun, rifle or shotgun?

39. Do you have any difficulty driving at high speeds in a motorized vehicle?

40. Have you ever had an automobile accident while driving over sixty (60) miles per hour?

41. Have you ever had any automobile accidents as a result of losing control of your vehicle?

42. Do you have any difficulty driving for three (3) consecutive hours without stopping?

43. Do you have any difficulty running for five (5) consecutive minutes without stopping?

44. Have you ever passed out, temporarily lost control of any part of your body, or had blackout spells (episodes you do not remember)?

(Continued on reverse side)

Page 3 F-1(LE) Rev. 6/11

Explanation of any “Yes” answers: (Identify by number)

Additional pages may be attached and must include your name, the last four digits of your social security number, and must be signed and dated.

________________________________________________________________________________________________

Penalty:

Any falsification, withholding or failure to answer all questions completely and accurately may disqualify you from receiving or retaining employment or certification as a criminal justice officer. Falsification regarding pre-existing conditions may disqualify you from receiving benefits from your employer.

Certification:

I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and answers to questions, and that all statements and answers are true and correct to the best of my knowledge and belief.

______________________________________________	_______________________________________
Signature of Applicant (Use Ink)	Date Signed
Qualified Medical Professional Review:
______________________________________________	_______________________________________
Signature of Qualified Medical Professional	Date Reviewed
(Use Ink)

Name, Title and Address of qualified medical professional completing review – Please Type.

Page 4 F-1(LE) Rev. 6/11

How to Edit Form F 1 Le Online for Free

Any time you desire to fill out Crohns, you won't have to download and install any kind of software - simply use our online tool. To make our editor better and easier to utilize, we consistently implement new features, with our users' feedback in mind. With some simple steps, it is possible to start your PDF journey:

Step 1: Firstly, access the pdf editor by pressing the "Get Form Button" above on this webpage.

Step 2: This editor allows you to modify nearly all PDF files in many different ways. Transform it by adding any text, adjust what is originally in the PDF, and include a signature - all when it's needed!

To be able to finalize this PDF document, make certain you enter the required details in every single blank:

1. Complete the Crohns with a group of essential fields. Collect all the necessary information and be sure absolutely nothing is overlooked!

2. Once your current task is complete, take the next step – fill out all of these fields - All Other Allergies food insects, and Page FLE Rev with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

3. This 3rd segment is considered quite simple, Past Medical History List ALL, CANCER any type of cancer, PSYCHOLOGICAL PROBLEMS such as, stress disorder and others, EYE PROBLEMS such as eye injury, blindness in one or both eyes very, EAR PROBLEMS such as ear injury, Menieres disease moderate to, NOSE PROBLEMS such as nose injury, lasting infections and others, and MOUTH OR THROAT PROBLEMS such as - all of these form fields must be filled out here.

4. Completing MOUTH OR THROAT PROBLEMS such as, LUNG PROBLEMS such as asthma, lung abscess and others, HEART AND CIRCULATION PROBLEMS, DIGESTIVE SYSTEM PROBLEMS such as, HORMONE OR ENDOCRINE PROBLEMS, problems and others, URINARY TRACT PROBLEMS such as, functioning kidney polycystic, HERNIA such as inguinal umbilical, BLOOD SYSTEM PROBLEMS such as, abnormality and others, and Continued on next page is vital in this fourth section - make sure to devote some time and fill in each field!

People generally make errors while filling out HERNIA such as inguinal umbilical in this section. Make sure you reread what you type in here.

5. To wrap up your form, the particular subsection includes a few extra blanks. Completing Males Only, Prostate problems such as, Females Only, Currently pregnant History of, menstrual cycle, Immunizations, Have you ever had a positive TB, Occupational History Have you ever, Repetitive Loud Noises Including, and Check all YES answers should finalize everything and you can be done in an instant!

Females Only, Males Only, and Repetitive Loud Noises Including of North_Carolina

Step 3: As soon as you've reviewed the details in the fields, simply click "Done" to complete your form. Sign up with us today and immediately use Crohns, all set for downloading. All adjustments you make are saved , letting you customize the pdf at a later stage when necessary. We do not share any details that you provide when working with documents at FormsPal.

Form F 1 Le – Fill Out and Use This PDF

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